Member Article

Clinical Documents’ Accuracy and Completeness Research Launched

In what’s claimed to be the first report of its kind to measure the impact of inaccurate and incomplete clinical documentation on patient care, clinicians and Health Trust operating costs, has been published by Nuance Communications. Entitled ‘The Clinical Documentation Challenge,’ the report uses the ‘Business Value of IT’ methodology to identify, measure and monetise the value of clinical documentation challenges.

Conducted by independent research company Ignetica, the report focused on a comprehensive map of core clinical pathways for acute providers, identifying the many different clinical documentation types that impact clinicians and patients. To ensure it was thorough, the research included interviews conducted with Chief Clinical Information Officers, as well as perception surveys undertaken with doctors, nurses, therapists and allied roles from four acute Health Trusts, in a bid to reflect the span of acute care across NHS England.

The top highlights from the research include:

1. 50% or more of a doctor´s time is spent on clinical documentation processes;

2. 52 minutes per day is spent searching for information;

3. In 27% of instances of reviewing clinical documentation, the required information was not available or had insufficient detail/clarity at the time required:

• 41% of these instances can be directly attributed to the completeness of medical notes

• 11.5 hours per week is spent adding to clinical documentation

• 68% or more of this time is generating narrative notes

4. 58% of the doctors highlighted that their notes were likely or very likely to be more complete if there was more time to spend on them;

5. The value of time searching for information is £19,474 per annum for senior doctors. Understanding the true story of a person’s health is becoming increasingly critical, but arguably it is also more complex than ever before. The study found that when clinical information is incomplete or inaccurate, multiple challenges can arise. These could include incurring additional work, process delays, potentially duplicated activities or risks associated with clinicians operating without the full information.

Peter Booth, CEO, Ignetica, explained: “While few would challenge the view that accuracy and completeness of clinical documentation is essential for integrated, effective, efficient and safe delivery of care, until today there has been little research, which extends through the patient and process factors to point to the wider economic implications. The research provides this insight for acute providers in England at a time when decisions made now about clinical documentation workflows will have implications for the quality of patient care and treatment in the future.”

The report is timely as many Health Trusts are on the cusp of making significant technology investments in Electronic Patient Records (“EPRs”) as well as other e-health initiatives in order to boost productivity and to realise the vision of a paperless NHS by 2018, while ensuring that patient and care records are digital, real-time and interoperable by 2020.

“Clinicians are at the very eye of the storm,” notes Frederik Brabant, Chief Medical Information Officer, Nuance Healthcare EMEA. “They are being asked to change the way they practice, to use EPRs in ways like never before, and to document many more things in much greater detail – from clinical decision making, to patient access and for analytics by the Health Trust. In the transition to EPRs, it’s important to communicate the complete patient story and not get caught up in just checking the boxes. Patient information is the heartbeat of the healthcare system and this stems from physician narrative and structured text, which ultimately enables hospitals and health systems to provide better care.” Nuance’s explains that its Healthcare solutions have the potential to improve the impacts described in the study. When speech recognition solutions are integrated into the EPR and other clinical documentation, it can help doctors, nurses and therapists to quickly and accurately capture the patient story at the point of care and transform it into meaningful, actionable information. Speech recognition can improve the completeness and accuracy of clinical documentation and help doctors, nurses and therapists to make better use of their precious time to focus on their patients.

Additionally, Nuance conducted a 3,000-person survey across the U.S., UK and Germany. It found that while 97% of patients are comfortable with technology in healthcare, the clinician-patient relationship plays a primary role in the overall patient experience and keeping people satisfied and invested in their health. The results, published in an eBook, “Healthcare from the Patient Perspective”, revealed the importance of clinicians establishing a personal connection with patients through eye contact, a handshake, a one on one conversation and privacy in the exam room. Findings demonstrated patients view technology as an enhancement that should play a supporting role in enhancing communication and information related to their healthcare.

This was posted in Bdaily's Members' News section by Pete Jackson .